Provider Demographics
NPI:1992231203
Name:KRAMER, ELIJAH LAKE (SAC-IT)
Entity type:Individual
Prefix:
First Name:ELIJAH
Middle Name:LAKE
Last Name:KRAMER
Suffix:
Gender:M
Credentials:SAC-IT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1016 MARY ST APT 4
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:WI
Mailing Address - Zip Code:53094-6747
Mailing Address - Country:US
Mailing Address - Phone:920-285-2453
Mailing Address - Fax:
Practice Address - Street 1:5325 W BURLEIGH ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53210-1623
Practice Address - Country:US
Practice Address - Phone:414-488-9512
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-05
Last Update Date:2017-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI18163101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)